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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 03/29/2024
Date Signed: 03/29/2024 02:08:13 PM

Document Has Been Signed on 03/29/2024 02:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VINTAGE HOMEFACILITY NUMBER:
198600544
ADMINISTRATOR:LINDA WILLIAMSFACILITY TYPE:
735
ADDRESS:5418 N. FAIRVALLEYTELEPHONE:
(626) 502-1055
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 6DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Direct Support Staff Henry EjezieTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/29/2024. LPA Ramirez was met by Direct Support Staff Henry Ejezie and explained the purpose of the visit. The facility is licensed to serve six (6) ambulatory Developmentally Disabled clients who are ages 18-59. Current client census is six (6). None of the clients has a Restricted Health Condition. Six (6) clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA Ramirez was attempted to conduct tour when C1 suddenly became physically aggressive with C2. Staff quickly intervened and separated C1 and C2. C1 became more aggressive as staff attempted to redirect C1. According to staff C1 becomes aggressive when new faces come around C1. For safety reasons, LPA Ramirez will return at a later time to conduct annual.

Exit interview conducted. A copy of this report was provided
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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